American Journ al of Nursing Science 2018; 7(2): 73-83 http://www.sciencepublishinggroup.com/j/ajns doi: 10.11648/j.ajns.20180702.15 ISSN: 2328-5745 (Print); ISSN: 2328-5753 (Online)

Effectiveness of Application of PLISSIT Counseling Model on Sexuality Among Women with Dyspareunia

Afaf Mohamed Mohamed Emam 1, Somaya Ouda Abd Elmenim 1, Samah Said Sabry 2

1Obstetrics and Woman's Health Nursing, Benha University, Benha, Egypt 2Community Health Nursing, Benha University, Benha, Egypt

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To cite this article: Afaf Mohamed Mohamed Emam, Somaya Ouda Abd Elmenim, Samah Said Sabry. Effectiveness of Application of PLISSIT Counseling Model on Sexuality Among Women with Dyspareunia. American Journal of Nursing Science . Vol. 7, No. 2, 2018, pp. 73-83. doi: 10.11648/j.ajns.20180702.15

Received : March 14, 2018; Accepted : April 2, 2018; Published : May 5, 2018

Abstract: Background: Dyspareunia is one of the most common but neglected female health problems which has a significant negative impact on a woman's sexual function. The aim of the study was to evaluate the effectiveness of application of PLISSIT counseling model on sexuality among women with dyspareunia. Design : A quasi experimental design was used. Setting: This study was conducted in outpatient clinic of obstetrics & gynecological department at Benha University Hospital. Sample: A purposive sample of all admitted women for a period of 6 months (280) woman: 200 out of them without dyspareunia and 80 with dyspareunia completed the PILLIST model. Tools: three tools were used I): A structured Interviewing Questionnaire Sheet. II): Dyspareunia assessment tool. III): Female Sexual Function Index (FSFI). Results: showed that the mean age of studied women were (35.21±9.03)years. More than one quarter of them complains of dyspareunia. there were statistically significant differences of the FSFI mean score between pre and post application as regard to elements of FSFI including desire, arousal, , satisfaction and pain (P<0.001). Meanwhile, there were no statistically significant differences regarding lubrication (P>0.4). Conclusion : PLISSIT counseling model had significant effect in improving sexuality among women with dyspareunia. The study recommended that the PLISSIT model should be used in a tailored and patient-centered approach in conducting sexual assessment and management of female dyspareunia. Keywords: Dyspareunia, Sexuality, PLISSIT Counseling Model

Dyspareunia may have a variety of causes. In order to 1. Introduction determine the cause, the location of the pain must first be The sexual pain disorders including dyspareunia are identified. Often, women will describe pain with intercourse highly prevalent yet misunderstood women's sexual health as deep and/or superficial. Deep dyspareunia as the pain is felt problems. Dyspareunia is term referring to painful sex which deep inside the pelvis during penile thrusting and superficial defined as persistent and recurrent urogenital pain occurring dyspareunia as pain experienced at the area of the vulva and before, during, or after , which is not introitus on penetration. The vast majority of women caused exclusively by lack of lubrication or by vaginismus. experienced superficial dyspareunia [4]. As reported in a study conducted by [1] dyspareunia affects The causes of dyspareunia may be mixed between 8–22% of women at some point during their lives, making it psychological, physiological, socio-cultural and interpersonal one of the most common pain problems in gynecologic causes. Psychological causes could result from fear of pain, practice. Moreover, It's one of the most frequently reported , interpersonal disturbance, stress or anxiety from co-morbidities in women with chronic pelvic pain with rates work or family responsibilities, concern about sexual ranging from 15% to 88% [2]. A worldwide prevalence of performance, conflicts in the relationship with partner, dyspareunia in systematic review is reported that, the rate of depression/anxiety, unresolved issues, dyspareunia range between 8 and 21.8% [3]. previous traumatic sexual or physical experience, body image and self-esteem problems. While , the common physical 74 Afaf Mohamed Mohamed Emam and Somaya Ouda Abd Elmenim: Effectiveness of Application of PLISSIT Counseling Model on Sexuality Among Women with Dyspareunia causes of dyspareunia include pelvic inflammatory disease, ''limited information'' about anatomical and physiological chronic pelvic pain, endometriosis, interstitial cystitis and aspects of the sexual function and providing correct irritable bowel syndrome. Also, diseases as thyroid disease, information about expected treatment effects on sexual and diabetes, heart, liver, and /or kidney disease, pelvic injury or reproductive function, without going into complete detail. trauma, pelvic surgery, neurological disorders, alcohol or drug Specific Suggestions (SS) giving specific suggestions for abuse and fatigue [5]. Any condition that results in poor managing common problems that occur during treatment. can cause discomfort during intercourse. Intensive Therapy (IT) in a few cases who there are complex The most common causes are drugs that have a drying effect underlying causes for their sexual problems intensive therapy such as antihistamines, certain tranquilizers, and manjuana, will be needed when their problems could not be resolved in and disorders such as vaginal infections, and estrogen the first 3 steps (such as intrapersonal conflicts or deficiencies [6]. psychological problems [13]. Dyspareunia has a significant negative impact on a woman's Nurse is an important member of the health care team to health, self-esteem, sexual relationships, quality of life, and counsel the women in the sensitive and highly charged area of work productivity [7]. Moreover, dyspareunia may lead to . Sexuality and sexual health problems are failure to reach orgasm, avoidance of sexual activity, challenging areas for nurses, so should be approached in a way relationship problems and place a woman at risk for the that respects women confidentiality and sensitively explores development of vaginismus. Therefore, careful measurement women needs [14]. Nursing interventions (Education and and description of pain is necessary [8] . [5] explored why counseling on sexuality) are used to assist women to resolve women with early genital pain delay treatment seeking. They their sexual problems [15]. found women cited a belief that the pain was normal, doubt that medical assistance would help and fear of the stigma of 1.1. Significance of the Study having a sexual problem. Therefore, [9] said that talking with Dyspareunia (Painful sex) is a common but neglected women about sexual pain disorders requires special attention female health problems with a prevalence of up to 39.5%, to the sensitivity of the issue and an empathic attitude to the imposing a significant burden on women’s sexual health and biological “truth” of pain this is the basis of a very rewarding relationship [1]. In Egypt 31.5% of women were suffered from clinician-patient relationship and is the basis of an effective dyspareunia as reported by [16]. therapeutic alliance. Because women with dyspareunia may experience a variety Today, clinical research indicates that combinations of of sexual health difficulties and their most significant barriers different treatments are much more useful than single to seeking help often result from embarrassment, stigma and therapies. As non-medication therapy is very important in beliefs about both the cause of the sexual pain and the efficacy dyspareunia, the use of counseling methods can also be of treatment. The nurse is an ideal member of the health team beneficial as women are advised to understand their problems to counsel women in the sensitive and highly charged area of and analyze them after identifying unknown issues. Numerous human sexuality. Therefore, sexual-counseling strategies can frameworks are available for sexual advice that can help be used by the nurses during the assessment and treatment health care providers to implement appropriate and effective processes [17]. Therefore, this study was aimed to evaluate the support strategies for intervention in the cases of sexual effectiveness of application of PLISSIT counseling model on concerns and problems [1]. sexuality among women with dyspareunia. In addition, sexual counseling is an interaction with women that includes information on sexual concerns and safe return to 1.2. Aim of the Study sexual activity, as well as assessment, support, and specific advice related to psychological and sexual problems, also The aim of this study was to evaluate the effectiveness of referred to as psychosexual counseling. Sexual counseling application of PLISSIT counseling model on sexuality among take place during a one-to-one exchange with a trained person, women with dyspareunia with the aim of solving problem and offering advice [10]. 1.3. Research Hypothesis The PLISSIT model was developed in 1976 by Jack Annon, is a counseling model for that can help PLISSIT counseling model will be effective for improving practitioners of all stripes address sexual health in their sexuality among women with dyspareunia women encounters. It has four steps, which start with very broad information-seeking and narrow to specific referrals 2. Subjects and Method and interventions for woman's issue [11] . The letters of the name refer to the four different levels of intervention 2.1. Research Design (permission P, limited information LI, specific suggestions SS and intensive therapy IT) [12]. A quasi-experimental (A pre-post- test) Design Was Used. The four level of PLISSIT model are: Permission 2.2. Setting (P)''giving permission'' to women to discuss issues of concern and encouraging to discuss problems which affect their sexual This study was conducted in outpatient clinic of obstetrics function negatively. Limited Information (LI) offering & gynecological department at Benha University Hospital, American Journal of Nursing Science 2018; 7(2): 73-83 75

affiliated to Benha city. This particular setting was chosen Part I : Socio-demographic data of studied sample such as because it is the main governmental hospital. This department (age, level of education, occupation, and residence). is specialized in providing maternity care for women with Part II: Menstrual /obstetric/and contraceptive history such different social backgrounds. as regularity of menstruation, menstrual pain, current usage of , parity status, history of previous episiotomy, 2.3. Subject previous perineal laceration and history of feeding. 2.3.1. Sample Type Part III: It was concerned with effect of dyspareunia on A Purposive Sample Was Used. frequency of sexual relation. 2.3.2. Sample Size 2.4.2. Second Tool: Dyspareunia Assessment Tool All women attended to the previously mentioned setting for Is was designed by the researcher after reviewing related six months were included in the study. The sample was literature to assess characteristics of dyspareunia such as the consisted of 280 women 200 women without dyspareunia and first time which women complained dyspareunia, timing of 80 women diagnosed with dyspareunia and selected according pain relative to intercourse, location of pain, frequency of pain, to inclusion criteria and exclusion criteria. intercourse position which pain occurs and severity of pain. The degree of severity of pain is determined according to 2.3.3. Inclusion Criteria Numeric Pain Intensity Scale developed by [18]. This 0 to 10 1. All recruited women were at reproductive age (15- 45) pain scale is commonly and successfully used to assess the yrs, complained of dyspareunia. degree and severity of pain. The values on the pain scale 2. Free from any gynecological disorders that may initiate correspond to pain levels as follows: 1-3 = mild pain, 4-6 = dyspareunia or moderate pain, 7-10 = severe pain. 3. Married and sexually active. 4. Willing to participate in the study 2.4.3. Third Tool: Female Sexual Function Index (FSFI) 5. Had a telephone. This scale was adopted from [19] it was designed as a multidimensional self-report questionnaire measure with 2.3.4. Exclusion Criteria subscales to assess the major components of sexual function in Pregnant women, women with major medical and/or women during the four weeks prior to the interview day. It psychiatric illness, Antidepressants, high blood pressure, consisted of 19-item self-report measure that assess six medications including sedatives and anti-histamines. domains including sexual desire, arousal, lubrication, orgasm, satisfaction and sexual pain. Each item yields a score ranging 2.4. Tools of Data Collection from 0 to 5. Scores obtained for each item are then summed up Three tools were used for collecting data. within each domain and then multiplied by a constant factor to yield woman domain scores. The overall sexual functioning 2.4.1. First Tool score is calculated by summing the domain scores. Lower A structured Interviewing Questionnaire Sheet: It was domain and overall sexual functioning scores indicate more designed by the researchers after reviewing related literature, sexual dysfunction and higher score indicating greater level of it was written in an Arabic language and encompassed three sexual functioning. major parts: Table 1. Distribution of the 6 domains of FSFI, the corresponding items, and their score range.

Domain Item /Number Score/ range Minimum score Maximum Score Desire 1, 2 1– 5 2 10 Arousal 3, 4, 5, 6 0– 5 0 20 Lubrication 7, 8, 9, 10 0– 5 0 20 Orgasm 11, 12, 13 0– 5 0 15 Satisfaction 14, 15, 16 0 (or 1)–5* 2 15 Pain 17, 18, 19 0– 5 0 15

*- Range for item 14 = 0–5; range for items 15 and 16 = 1–5

2.5. Methods 2.5.2. Tools Validity The study was executed according to the following steps: The validity of questionnaires were reviewed for content validity by a jury of five experts in the field of obstetrics & 2.5.1. Approvals woman health nursing at Ain shams university and A written official approval to conduct this research was El-Menoufia university to ascertain relevance and obtained from the director of Benha University Hospital that completeness of tools. Moreover, the validity of FSFI was was taken and delivered to the director of the outpatient clinics, confirmed by Rosen et al. and Anis et al. [19, 20] in order to obtain their agreement to conduct the study after explaining its purpose. 76 Afaf Mohamed Mohamed Emam and Somaya Ouda Abd Elmenim: Effectiveness of Application of PLISSIT Counseling Model on Sexuality Among Women with Dyspareunia

2.5.3. Tools Reliability face-to-face interview technique, facilitated filling a Reliability was done by using Cronbach's Alpha coefficient structured interviewing questionnaires, dyspareunia test which revealed that each of the two tools consisted of assessment tool and apply pre test to those women by using relatively homogenous items as indicted by the high reliability. Female Sexual Function Index(FSFI) to assess their sexual Internal consistency of FSFI=0.89 and dyspareunia functions. The number of interviewed women per week was assessment tool = 0.83. According to [21] values equal or 10-11 women. The average time taken for filling each sheet greater than 0.70 considered satisfactory. was around 15-20 minutes depending on the response of the women. Each woman was reassured that information 2.5.4. Ethical Considerations obtained would be confidential and used only for the purpose Ethical approval was obtained from the Scientific Ethical of the study. Committee of Benha University. The purpose of the study was 2. Planning Phase: explained to each woman and informed consent was obtained Based on pre-test assessment the content and framework of from them to participate in this study. Confidentiality of the counseling sessions were prepared by the researchers obtained personal data, as well as respect of women’s privacy based on women's needs after reviewing related literature was totally ensured. A summary of the intervention was using the general principles of the PLISSIT Counseling explained to each woman before volunteering to participate in model through application of four levels permission(P), the study and women were informed that they can withdraw limited information(LI), specific suggestions(SS), and from the study at any time. No invasive procedure was intensive therapy(IT). required. The protocol of this study has been approved by the 3. Implementation Phase: Hospital. The researchers conducted the counseling sessions in 2.5.5. The Pilot Study outpatient clinic affiliated at obstetrics and gynecological The pilot study was carried out before starting data department at Benha University Hospital. The researchers collection. It was done to estimate the time required for filling visited the above mentioned setting three days/week from out the sheets and also to check the simplicity, clarity, 9.00 am to12.00 pm. Four week one hour individual applicability and feasibility of the developed tools. The pilot (one-to-one) sex counseling sessions were carried out by the study was conducted on 10% of total sample (8)women. researchers. The researchers established the session's Based on the results of the pilot study, the necessary environment to be comfortable and quiet. They used a well modification were done, sample involved in the pilot study prepared intervention materials and contents in the form of was excluded from the main study sample. comprehensive illustrated booklet and educational videos related to the sexuality by using PLISSIT Model. 2.5.6. Procedures 1- Permission is the first level of the model which the Official approvals and letters to conduct this study were researchers gave the women permission to initiate sexual obtained from dean of researchers' faculty to directors of the discussion, feel comfortable about a topic or empower the previous mentioned settings. Informed consents were women to make choices and changes, performing the obtained from selected women and the aim of the study was assessment, create a comfortable and open-minded climate, explained to them. The study was carried out from beginning demonstrate active listening, freely interact with the women of June 2017 to the end of December 2017 covering a period and her partner, simply ask questions about all aspects of of six months. sexual health to give the women the opportunity (permission) - Preparatory Phase: to share her sexuality and what it means to them, and identify The research design and tools of data collection was any concerns. However, the woman may hesitate or feel prepared based on reviewing current & past, local and embarrassed to describe her sexual problems; therefore, the international related literature by using magazines, books, researchers explain that sexuality is an essential periodicals journal and computer search to construct the tool quality-of-life issue, and advice the women to be open to of the study. Also prepared the counseling program for discuss it. This helps to normalize the discussion and may women with dyspareunia, the content of this program was help the women feel less embarrassed or alone. prepared based on [11] PLISSIT Model of Intervention 2- The second level is Limited Information, refers to related to dyspareunia was developed and converted into a factual information given to the women in response to a beneficial booklet question or observation. Where in the researcher supplied the This study conducted through four sequential phases: women with limited and specific information on the topics of 1. Assessment Phase: discussion, addressed prevalent sexual concerns, norms of This phase encompassed interviewing the women to behavior and attempt to correct myths and misinformation collect baseline data, at the beginning of interview the about dyspareunia and its treatment. The researcher teach the researchers greeted each women, introduce themselves, women about the basic anatomy of the genital organ and explained the aim of the study, scheduled times and physiological response of sexual function, and explain how frequency of counseling sessions to all selected women to diseases or treatment may affect sexual functioning and what assure adherence to selected interventions. After taken oral changes in anatomy occur after surgery or birth delivery. consent each woman was interviewed individually using a Moreover, the researcher emphasize on the importance of American Journal of Nursing Science 2018; 7(2): 73-83 77

communication and trust within a partner relationship; dispel without dyspareunia, it was observed that more than one misconceptions and lead to the sharing of accurate quarter (28.60%) of the studied sample complains of information; and review the needs for sexual health, comfort, dyspareunia. belief, and emotional safety. Table 3 Describes menstrual, obstetric and contraceptive 3 -Specific Suggestions is the third level of PLISSIT model. history of the studied sample. As shown, more than half After explaining the sexual concerns and how a woman has (56.2% 54.0%) of women with and without dyspareunia had evolved over time, the researchers explained the causes of the irregular menstruation respectively, also more than half problems and assist the woman with very specific directions (58.6%) of them complain pain during menstruation, the on how to address the problems. This can include suggestions majority of them (85.0%, 89.0%) were use contraceptive on how to deal with sex related diseases or information on methods respectively, more than half (58.8%, 53.4%) of how to better achieve sexual satisfaction by the women's these women using IUD respectively. And less than two changing their sexual behavior. The suggestions may third (60.3%) of women with dyspareunia had vaginal alternative methods of sexual expression such as Crosswise delivery with statistically significant differences among sexual position and Kegel exercise may be suggested to help women with and without dyspareunia regarding parity the woman relax the pelvic floor muscles or can involve status, history of previous episiotomy, history of previous specific regimens of activity or medication. perineal laceration and type of family planning method used 4 -The fourth and final level is Intensive Therapy, which (P<0.05). has the researchers provide the women guidance for the Table 4 Shows that, less than half (45.0%) of women with treatment for severe or more longstanding problem of dyspareunia had sexual relation 1-2 times per/week compared dyspareunia. If necessary, the researchers can be made a with more than half (51.0%) of women without dyspareunia referral to a sexual health specialist, such as a sex therapist, had 3-4 times/week with highly statistical significance pelvic floor specialist, or sex educator to provide more differences among the studied sample in relation to effect of comprehensive support and guidance. dyspareunia on frequency of sexual relation(P<0.001).. 4. Evaluation Phase: Table 5 Clarifies the characteristics of dyspareunia among The post test was done after application of PLISSIT the studied sample, it shows that, less than two third (61.3%) counseling model. The researchers were used the same of women complain of dyspareunia from beginning of previous tools such as Female Sexual Function Index(FSFI) to , while more than one quarter (28.8%) of them evaluate the effectiveness of application of PLISSIT complain dyspareunia after delivery, less than half (45.0%) of counseling model on sexuality among women with dyspareunia them had dyspareunia at the mid-time of vaginal introitus, more than one third (36.3%) of them had persistent 2.5.7. Statistical Analysis dyspareunia with each sexual relation, less than half (47.0 %) Data entry and statistical analysis was done using of them complain dyspareunia when use man on above Statistical Packages for Social Science (SPSS) version 20. position. In addition, more than three quarter (76.3%) of Quality control was done at the stages of coding and data women had moderate degree of pain. And (72.5%) of them entry. Data were presented using descriptive statistics in the had pain during intercourse form of frequencies and percentages for qualitative variables, Table 6 represents Female Sexual Function Index (FSFI) and means and standard deviations for quantitative variables. mean score among the studied sample with dyspareunia pre Qualitative variables were compared using chi-square test. and post implementing PILLIST model. As shown, there was Statistical significance was considered at p-value <0.05, statistically significant differences of the FSFI mean score pre highly significant difference obtained at P<0.00l and non and post intervention (P<0.001**) as regard to elements of significant difference obtained at P > 0.05 FSFI including desire, arousal, orgasm, satisfaction and pain. Meanwhile, there were no statistically significant differences 3. Results regarding lubrication (P>0.4). Moreover, total sexual function score pre and post were (53.20± 2.92) and (73.66±2.94) Table 2 Describes socio-demographic data of the studied respectively this indicated highly significant differences (P> sample with and without dyspareunia. As inferred from the 0.001**). table, the age of studied women was ranged between 20-45 years, with a mean age of (34.68±8.98) years for women with dyspareunia and (35.42±9.07)years for women without dyspareunia. Secondary school education represented the higher percent by (55.7%) followed by those who had university education (17.5%), nearly two third of studied women were house wife (66.4%), less than two third (63.6%) of them are live in rural areas. There was no statistically Figure 1. Percentage distribution of studied women with and without significant differences with various socio-demographic data. dysparunia. Figure 1 Shows percentage distribution of women with &

78 Afaf Mohamed Mohamed Emam and Somaya Ouda Abd Elmenim: Effectiveness of Application of PLISSIT Counseling Model on Sexuality Among Women with Dyspareunia

Table 2. Distribution of the studied sample according to socio-demographic data (N=280).

Dyspreunia (80) No dyspareunia (200) Total (280) Test of significance Variable No % No % No % t-test or χ2 P Value Age (years): Mean ± SD 34.68± 8.98 35.42± 9.07 35.21± 9.03 65.21 0.32 Educational level Illiterate 5 6.3 10 5.0 15 5.4 0.16 Read and write 7 8.8 17 8.5 24 8.6 Preparatory 20 25.0 16 8.0 36 12.9 234.89 Secondary 30 37.5 126 63.0 156 55.7 University 18 22.5 31 15.5 49 17.5 Occupation: Working 35 43.8 59 29.5 94 33.6 0.40 30.22 Housewife 45 56.3 141 70.5 186 66.4 Residence: Rural 44 55.0 134 67.0 178 63.6 0.16 20.6 Urban 36 45.0 66 33.0 102 36.4

χ2: Chi-Square test, t: Independent t test.

Table 3. Distribution of the studied sample according to menstrual, obstetric and contraceptive history N=280.

Dyspreunia No dyspreunia Test of significance Variable (80) (200) No % No % χ2 P Value Regulatory of menstruation Regular 35 43.8 92 46.0 2.414 0.12 Irregular 45 56.2 108 54.0 Pain during menstruation: Yes 47 58.8 117 58.5 8.22 0.06 No 33 41.3 83 41.5 Current usage of contraceptive methods Yes 68 85.0 178 89.0 0.23 160.5 No 12 15.0 22 11.0 If yes, type of contraceptive methods Progestin only pills 15 18.8 42 21.0 0.05* Combined pills 7 8.8 31 15.5 IUD 52 65.0 117 58.5 316.14 Norplant 3 3.8 6 3.0 Injectable contraceptive 3 3.8 4 2.0 Parity status No 7 8.8 15 7.5 0.05* Vaginal 44 55.0 86 43.0 81.80 Cesarean section 29 36.3 99 49.5 History of previous episiotomy Yes 36 45.0 69 34.5 0.04* 17.50 No 44 55.0 131 65.5 History of previous perineal laceration Yes 32 40.0 46 23.0 0.03* 54.91 No 48 60.0 154 77.0 History of breast feeding: Yes 70 87.5 171 85.5 0.06 145.7 No 10 12.5 29 14.5

χ2: Chi-Square test, *Statistical significant difference (P≤0.05*)

Table 4. Distribution of the studied sample according to effect of dyspareunia on frequency of sexual relation N=280.

Total (280) Test of significance Frequency of sexual relation Dyspreunia (80) No dyspreunia (200) No % No % χ2 P Value Once per month 8 10.0 12 6.0 <0.001** 2 per month 13 16.3 17 8.5 1-2 per week 36 45.0 39 19.5 119.67 3-4 per week 17 21.3 102 51.0 More than 4 per week 6 7.5 30 15.0

χ2: Chi-Square test, **A highly statistical significant difference (p≤0.001) American Journal of Nursing Science 2018; 7(2): 73-83 79

Table 5. Distribution of the studied sample according to characteristics of dyspareunia (N=80).

Dyspreunia (80) Characteristics of dyspareunia No % First time which complained dyspareunia From beginning of marriage 49 61.3 After delivery 23 28.8 After menstruation 8 10.0 Timing of pain relative to intercourse Before 12 15.0 During 58 72.5 After 10 12.5 Location of pain Superficial pain felt at or near vaginal introitus on penetration 25 31.3 At the middle of 42 45.0 Deep pain felt inside the pelvis during penile thrusting 13 16.3 All of the above 6 7.5 Frequency of dyspareunia Continuous 29 36.3 Intermittent 51 63.8 Intercourse position which pain occurs When man above 38 47.5 When women above 10 12.5 Side-lying position 18 22.5 Cross –wise position 14 17.5 Severity of pain Mild 10 12.5 Moderate 61 76.3 Severe 9 11.3

Table 6. The mean score of Female Sexual Function Index (FSFI) among the studied women with dyspareunia Pre & Post intervention (N=80).

Pre- intervention N=80 Post -intervention N= 80 Female Sexual Function Index T test P Value Mean ± SD Mean ± SD Desire (2 items) 4.13 ± 0.66 8.30 ± 0.72 13.62 < 0.001** Arousal (4 items) 12.28 ± 1.61 16.73±0.77 7.76 < 0.001** Lubrication (4 items) 12.90 ± 1.68 13.25 ± 1.61 3.64 0.47 Orgasm (3 items) 8.68 ± 1.13 9.90 ± 1.31 7.27 0.04* Satisfaction (3 items) 8.45± 0.926 12.10± 0.58 28.15 < 0.001** Pain (3 items) 6.75 ± 0.77 13.37± 0.64 54.68 < 0.001** Total score 53.20± 2.92 73.66±2.94 32.65 < 0.001**

T: paired T test, no statistical significant difference (P> 0.05). Statistical significant difference (P<0.05*) **A highly statistical significant difference (P ≤0.001)

use of a family planning method. 4. Discussion As regards socio-demographic data of studied sample the The sexual pain disorders including dyspareunia are highly findings of present study revealed that the mean age of women prevalent yet misunderstood women's sexual health problems with dyspareunia were (34.68± 8.98) and (35.42± 9.07) years due to cultural and traditional believes and embarrassment in in women without dyspareunia with no statistical significant discussing the issues of sexuality or the women may perceive differences. This indicated that women with and without it as a private topic and must not be discussed with foreigner dyspareunia were homogenous before conduction of the study. health care provider [22]. The PLISSIT model for assessment This findings was congruent with Mansour et al. [23] who and treatment of sexual health is useful tool that gives basic study the effect of sexual counseling program on pain level structure to sexual inquiry and treatment [12]. So that the and sexual function among women with dyspareunia and study aimed to evaluate the effectiveness of (PLISSIT) found that dyspareunia is common at reproductive age counseling model on sexuality among women with between 20-40 years. Also approved with KR Mitchell et al. dyspareunia. [24] who studied Painful sex (dyspareunia) in women, The results of this study will be discussed in frame of prevalence and associated factors in a British population previously mentioned research hypothesis. To determine the probability survey and found that proportion reporting painful associated factors related to dyspareunia, a comparison sex is highest in young women (16–40 years). In addition, this between women with dyspareunia and women without findings are in the same line with Liu et al. [25] who study dyspareunia was done. These factors included dyspareunia and its comorbidities among Taiwanese women socio-demographic data and obstetric features as regularity of and found that the incidence of dyspareunia was higher among menstruation, partial status, history of previous episiotomy, women aged 30–34 years. On the other hand, this findings is history of previous perineal laceration, breastfeeding, and the contradicted with Saboula and Shahin [26] who studied the 80 Afaf Mohamed Mohamed Emam and Somaya Ouda Abd Elmenim: Effectiveness of Application of PLISSIT Counseling Model on Sexuality Among Women with Dyspareunia effect of cognitive behavioral therapy on women with dyspareunia, according to their study is significant (p˂0.001). dyspareunia and reveled that there were statistical significant Also consistent with Boran et al. [33] who studied the differences between the studied groups regarding age. Also, episiotomy and the development of postpartum dyspareunia disagree with Hendrickx et al. [27] In their study about and anal incontinence in nulliparous females and found that Age-related prevalence rates of sexual difficulties, sexual episiotomy is associated with dyspareunia. On the other hand, dysfunctions, and sexual distress in heterosexual women this result is contradicted with Dabiri et al. [34] who studied which found most sexual difficulties and sexual dysfunctions the effect of mode of delivery on postpartum sexual increase with age. Furthermore, it was found that-except for functioning in primiparous women and found no significant lubrication difficulties-sexual distress was also significantly association between mode of delivery and postpartum associated with age. dyspareunia. The findings of present study revealed no statistically Regarding previous perineal laceration, the present study significant differences between women with and without findings revealed that women with dyspareunia had perineal dyspareunia regarding educational level, occupation and laceration more than women without dyspareunia, this result residence. This findings were approved by Mansour et al. [24] was similar to findings of study done by Meir Medical Center who found no differences with various socio-demographic [35] who found that postpartum dyspareunia resulting from data between studied sample. Also, in the same line with vaginal atrophy that evaluated the prevalence and the causes Sobhgol et al. [28] who did not find any relation between for postpartum dyspareunia referred primarily to obstetric employment status and dyspareunia. On other hand, this trauma, such as vaginal tears. Regarding breast feeding, the findings are disagreement with Dean et al. [29] who studied present study findings revealed that the majority of women dyspareunia in women and found that significant risk factors with dyspareunia had breast feeding. This result in the same and predictors for dyspareunia include education level below a line with Khajehei [36] in their study about the comparison of college degree. sexual outcomes in primiparous women experiencing vaginal The current study results confirmed that minority of the and caesarean births and found that women who breastfed studied sample complain of dyspareunia. This percent may not their infants were less interested in starting intercourse. reflect the actual percentage of cases due to cultural and The present study illustrated that less than half of women traditional believes and embarrassment in discussing the with dyspareunia decrease frequency of sexual relation than issues of sexuality. This findings in the same line with KR woman without dyspareunia. This result in the same line with Mitchell et al. [23] who revealed that painful sex was reported Thomas et al. [37] in their study on dyspareunia is associated by 7.5% of sexually active women of whom one quarter with decreased frequency of intercourse in the menopausal experienced symptoms very often or always, for ≥6 months, transition and reported that women who report dyspareunia, and causing distress. but not vaginal dryness report less frequent intercourse. Relief Concerning type of contraceptive methods, the results of of dyspareunia should be addressed to maintain sexual the present study revealed that more than half women with functioning during mid-life. and without dyspareunia use IUD method. This result The results of the current study showed that, less than half disagree with Steege and Zolnoun [30] who found that of women with dyspareunia complains onset of pain at the Perhaps in keeping with the evidence for higher prevalence mid-time of vagina introitus, one third at the beginning and of vulvar vestibular syndrome in women using few at the end of vaginal introitus. This results supported by very-low-dose estrogen pills for long periods of time, some Orawan and Taneepanichskul [38] who reported that, among clinicians have observed that very light menses can be women with dyspareunia (47 in 108 women) found 51% had associated with diminished vaginal lubrication, leading to pain during the course of lovemaking, 34 % after and 15% at dyspareunia. Also contradicted with [31] who studied the beginning of lovemaking. contraception and sexuality and stated that progesterone only Regarding position of intercourse which cause dyspareunia method can in small numbers decrease and cause the results of the present study illustrated that less than half of vaginal dryness consequently dyspareunia. women complains from dyspareunia when the man above but As regards partial status, the present study findings revealed few percent complain from dyspareunia when position of that, more than half of women with dyspareunia had vaginal woman above during sexual relation. This result in the same delivery and the majority of them had previous episiotomy. line with Saboula and Shahin [26] who reported that 32% of This may interpreted as low estrogen levels after delivery and women complained of dyspareunia were used man on the top local injury to the genital area at delivery may result in pain position. On the other hand, this result was disagree with John with sexual activity. This finding was matching with previous et al. [39]who found that the cross-wise position was perhaps study done by Abd Alkareem et al. [32] who studied the the best position for decreasing dyspareunia than other prevalence and risk factors of postpartum dyspareunia at three positions as when employed properly, neither partner is months post- delivery in Sudanese women and reported that supporting their weight, the external genitalia are available for an increase rate of postpartum dyspareunia among women additional stimulation, and both direction and depth of vaginal who had a vaginal delivery underwent a mediolateral penetration can be easily adjusted. episiotomy than others bearing by cesarean section. The The results of the present study revealed that two third of relation between mode of delivery and postpartum women complains dyspareunia from beginning of marriage American Journal of Nursing Science 2018; 7(2): 73-83 81

during initiation of sexual intercourse and about one quarter (P>0.4). complains dyspareunia after delivery. This result disagree with Alexander et al. [40] who reported that dyspareunia in 41 % Recommendations to 67% of women within 2 to 3 months after birth and is associated with perineal trauma during delivery, episiotomy In the light of the findings of current study the following discomfort, decreased lubrication and vaginal dryness recommendations were be suggested: resulting from decreased estrogen levels, breast feeding, and 1. The PLISSIT counseling model should be used in a tailored pelvic floor dysfunction all have been linked to dyspareunia and patient-centered approach in conducting sexual after birth. assessment and management of female dyspareunia. As regards Female Sexual Function Index the results of 2. In service education program for nurses about how to the current study revealed that there were statistically deal and manage various sexual problems by using significant differences between pre and post application of PLISSIT counseling model. PILLIST model (P<0.001) as regard to elements of Female 3. Replication of PLISSIT counseling model on wide range Sexual Function Index (FSFI) including desire, arousal, of women complaining dyspareunia in outpatient clinics. orgasm, satisfaction and pain. Meanwhile, there were no 4. Sexual problems should be included in the Ministry of statistically significant differences regarding lubrication Health and Population plan to care for women with (P>0.4).This finding can be explained by how this model dyspareunia. incorporates four levels; for problems of the first level, the participants are allowed to talk about their sexual problems. Limitations of the Study This result in the same line with Mansour et al. [23] who reported that statistical significant differences between pre Some participated women withdrawn from the study after and post scores in favor of post. All women post intervention filling the interview questionnaire, because they cited a belief mean scores were higher than pre intervention mean scores. that the pain was normal, fear of the stigma of having a sexual As showed that after counseling sessions women's scores problem and considered the sexual issues are prevented to be were significantly higher than before with regard to desire, discussed openly (culture issue). arousal, satisfaction, orgasm and pain. Also the study revealed that there were no statistically significant difference Acknowledgements regarding lubrication. Also, this result congruent with Torkzahrani et al. [41] who The authors would like to express gratitude and reported that mean scores of sexual function four weeks after appreciations to all women who willingly participated in this consultation were higher in experimental groups than in study for their effective cooperation control group with high significant difference (P<0.001). Based on the result of this study, sexual problems decreased by using the PLISSIT model and consistent with Rostamkhani References et al. [42] who reported that significant improvement was found in FSFI sub-domain scores, including sexual desire, [1] Sunga, S. C., Jenge, C. J., and Linb, Y. C (2011): Sexual health care for women with dyspareunia. Taiwan. J. Obstet. Gynecol. arousal, orgasm, satisfaction and pain. Also in FSFI total score 50 (3), 268–274 (2011). in the intervention group compared to the control group. 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